Pulmonary cryptococcosis in routine care: the clinical–radiologic spectrum and transparent evidence-tier reporting (confirmed versus presumed) among patients with no recorded immunocompromising conditions

Introduction. Pulmonary cryptococcosis is increasingly identified in routine care, including among patients with no recorded immunocompromising conditions.Hypothesis/Gap Statement. Real-world descriptions of pulmonary cryptococcosis are difficult to interpret because diagnostic intensity and case definitions vary across studies, and many cohorts reflect pathway-based rather than population-based case capture.Aim. This study aimed to describe the clinical presentation, including asymptomatic/incidental cases, and chest computed tomography (CT) patterns of pulmonary cryptococcosis by two-level immune status, and to report prespecified diagnostic evidence tiers (confirmed vs presumed).Methodology. We conducted a single-centre, retrospective, observational study at a tertiary hospital in China (January 2016 to December 2020). The analytic cohort comprised adjudicated pulmonary cryptococcosis cases identified along a routine-care diagnostic pathway among patients with pulmonary imaging abnormalities who underwent serum cryptococcal antigen testing as part of clinical evaluation. Cases were classified using a prespecified two-tier evidence scheme (confirmed vs presumed).Results. Among 62 cases, 23/62 (37.1%) were immunocompromised, and 39/62 (62.9%) had no recorded immunocompromising conditions. Evidence tiers comprised 32/62 (51.6%) confirmed and 30/62 (48.4%) presumed cases. Cryptococcal meningitis was documented in 11/62 (17.7%). Asymptomatic/incidental presentation was recorded in 16/62 (25.8%), including 4/23 (17.4%) immunocompromised cases and 12/39 (30.8%) cases with no recorded immunocompromising conditions. On chest CT, nodules/masses were the most frequently recorded pattern in both groups, observed in 17/23 (73.9%) and 31/39 (79.5%) cases, respectively. Opacities/consolidation, cavitation and loculated pleural effusion were recorded less often.Conclusion. In this routine-care diagnostic-pathway cohort, nodules/masses were the most frequently recorded CT pattern, and asymptomatic/incidental presentation was documented in a substantial proportion of cases, including among patients with no recorded immunocompromising conditions. Separate reporting of confirmed and presumed cases may improve interpretation of cohorts assembled under non-uniform diagnostic work-up.